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Invited Commentary
November 2016

Tipping the Balance Toward Fewer Antibiotics

Author Affiliations
  • 1Harvard Medical School, Boston, Massachusetts
  • 2Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3Division of General Internal Medicine and Primary Care, Brigham & Women’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2016;176(11):1649-1650. doi:10.1001/jamainternmed.2016.6254

News of patients with broadly resistant “superbugs” have recently raised public awareness of the risks of antibiotic overuse. But unnecessary antibiotic use is not a new problem; it has been a public health priority for decades and 2 new articles1,2 in the current issue of JAMA Internal Medicine illustrate the persistence of this problem. A number of initiatives have been attempted to address antibiotic overuse, and there was initial success with a roughly 20% reduction in outpatient antibiotic prescribing per capita.3 But those efforts have stalled, rates of outpatient antibiotic prescribing have remained stagnant, and, most troubling, an increasing fraction of prescriptions are for broad-spectrum antibiotics. The reality is that in the outpatient setting at least one-third of all antibiotics are prescribed unnecessarily.4 In hospitals there are similar trends. Baggs and colleagues1 found that the use of antibiotics per hospital day did not change between 2006 and 2012 and that the use of broad-spectrum antibiotics increased.

To address these troubling trends, a number of tactics are being considered. One strategy is to educate physicians both on the latest evidence and general concerns on antibiotic overuse. For example, the Centers for Disease Control and Prevention’s (CDC) Get Smart campaign has emphasized that physicians need to be better antibiotic stewards. Unfortunately, physician educational efforts have had little effect. For example, despite widely disseminated guidelines emphasizing that antibiotics for acute bronchitis are not indicated, 76% of visits to a physician office for bronchitis result in an antibiotic prescription.5 Almost all physicians already know that avoiding antibiotics for viral conditions is the right thing to do, and physicians’ knowledge of guidelines has no association with their likelihood of prescribing an antibiotic.6 In the current issue of JAMA Internal Medicine, Johnston and colleagues2 demonstrate that antibiotics for asthma exacerbation do not improve outcomes. Sadly, prior experience portends that this well-conducted study will not curtail antibiotic prescribing. Indeed, the current culture of overuse of antibiotics made it difficult for these investigators to even find patients who had not already received antibiotics for an asthma exacerbation.

Another proposed tactic to address antibiotic overuse is better diagnostics; diagnostics play a prominent role in the United States’ National Action Plan for Combating Antibiotic-Resistant Bacteria (https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf) and the United Kingdom’s Review on Antimicrobial Resistance’s Tackling Drug-Resistant Infections Globally (http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf). While we recognize their appeal, improved diagnostics may also have limited impact. Highly sensitive tests may create confusion through false-positive results. More important, new tests will not help with diagnoses of colds, sinusitis, or acute bronchitis, which collectively account for the majority of inappropriate antibiotic prescribing.

The overuse of antibiotics is not a knowledge problem or a diagnostic problem; it is largely a psychological problem. More specifically there are strong factors pushing the physician toward prescribing an antibiotic and weaker factors pushing against (Box). The reasons for antibiotic prescribing are emotionally salient. We, as physicians, want to appear capable to our patients and not give the impression they have wasted either our time or their own. In addition, it feels easier for us as physicians to do something now rather than wait for a problem to arise. In circumstances of diagnostic uncertainty, prescribing antibiotics “just to be safe” feels like it decreases the chance of serious complications. Physicians also perceive that patients want an antibiotic prescribed, and in a rushed visit it seems faster to write the prescription than explain to the patient why an antibiotic is not necessary. In contrast, the reasons against antibiotic prescribing such as antibiotic resistance and concerns about complications are remote and less emotionally salient. Given the clear imbalance in this tradeoff, it is not surprising that many physicians inappropriately prescribe an antibiotic.

Box Section Ref ID
Box.

The Imbalance in Factors Related to Antibiotic Prescribing

Factors Driving Antibiotic Prescribing: Immediate and Emotionally Salient
  • Belief that a patient wants antibiotics

  • Perception that it is easier and quicker to prescribe antibiotics than explain why they are unnecessary

  • Habit

  • Worry about serious complications and “just to be safe” mentality

Factors Deterring Antibiotic Prescribing: More Remote and Less Emotionally Salient
  • Risks of adverse reactions and drug interactions

  • Recognizing the need for antibiotic stewardship

  • Desire to deter low-value care and decrease unnecessary health care spending

  • Prefer to follow guidelines

How do we tip the balance and decrease inappropriate antibiotic prescribing? We recommend 3 potential strategies. First, we should reframe the rationale against antibiotic prescribing from a public health concern to an individual patient concern. For the patient being prescribed an antibiotic there are many potential harms including rashes, diarrhea, Clostridium difficile infection, mucosal fungal infections, life-threatening allergic reactions, and harboring antibiotic-resistant bacteria for a time.7 These harms outweigh the benefits; this is why prescriptions are inappropriate. But it would be useful to quantify those risks for an individual patient under different clinical scenarios, thereby making those concerns more salient to the physician and the patient.

Second, we recommend greater use of social psychology and behavioral science strategies to reduce antibiotic overprescribing. Order entry systems that force physicians to provide a publically visible justification for prescription reduced inappropriate antibiotic prescribing from 23% down to 5%.8 Periodic peer comparison feedback, including informing physicians when they are “not a top performer,” makes physicians think about their professional reputation when they prescribe an antibiotic. Such feedback reduced inappropriate antibiotic prescribing from 20% to 4%.8 While these interventions may seem heavy handed, retail clinics (settings that many physicians consider competition) use similar and even more intrusive interventions, like routine audits, successfully. Contrary to concerns from the physician community, antibiotic prescriptions at retail clinics are more guideline concordant and less likely to be broad spectrum.5

Third, for ambulatory visits the ultimate way of tipping the balance against antibiotic overprescribing is to prevent the visit in the first place. Office visits for colds, sinusitis, or acute bronchitis should be viewed as wasteful, error-prone events; patients are spending valuable time going to the doctor and putting themselves at risk for exposure to a potentially harmful chemical. Internet tools or smart phone apps could help patients self-triage and thereby only seek care when there is a higher likelihood they will need antibiotics. Current self-triage tools clearly need improvement but are growing in popularity.9 Routine use of better self-triage tools could deter many inappropriate antibiotic prescriptions.

The dramatic variation in antibiotic prescribing across individual clinicians, regions in the United States, and internationally indicates great potential for improvement. In a single health system, physicians’ antibiotic prescribing rates for some conditions vary more than 2-fold.6 In the article by Baggs et al,1 inpatient antibiotic prescribing in some regions of the United States is roughly 20% lower than other regions. On a per capita basis, Swedes consume less than half the antibiotics per capita than Americans.10

Growing patterns of antibiotic resistance have driven calls for more physician education and new diagnostics. While these efforts may help, it is important to recognize that many emotionally salient factors are driving physicians to inappropriately prescribe antibiotics. Future interventions need to counterbalance these factors using tools from behavioral science to reduce the use of inappropriate antibiotics.

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Article Information

Corresponding Author: Ateev Mehrotra, MD, MPH, Harvard Medical School, 180A Longwood Ave, Boston, MA 02115 (Mehrotra@hcp.med.harvard.edu).

Correction: This article was corrected on April 24, 2017, to delete a redundant sentence in the sixth paragraph.

Published Online: September 19, 2016. doi:10.1001/jamainternmed.2016.6254

Conflict of Interest Disclosures: None reported.

Additional Contributions: Dr Linder would like to thank his BEARI (Behavioral Economics/Acute Respiratory Infection) Coinvestigators.

References
1.
Baggs  J, Fridkin  SK, Pollack  LA, Srinivasan  A, Jernigan  JA.  Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012  [published online September 19, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.5651Google Scholar
2.
Johnston  SL, Szigeti  M, Cross  M,  et al.  The Azithromycin for acute exacerbations of asthma: the AZALEA randomized clinical trial  [published online September 19, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.5664Google Scholar
3.
Grijalva  CG, Nuorti  JP, Griffin  MR.  Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.  JAMA. 2009;302(7):758-766.PubMedGoogle ScholarCrossref
4.
Fleming-Dutra  KE, Hersh  AL, Shapiro  DJ,  et al.  Prevalence of inappropriate antibiotic prescriptions among us ambulatory care visits, 2010-2011.  JAMA. 2016;315(17):1864-1873.PubMedGoogle ScholarCrossref
5.
Mehrotra  A, Gidengil  CA, Setodji  CM, Burns  RM, Linder  JA.  Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments.  Am J Manag Care. 2015;21(4):294-302.PubMedGoogle Scholar
6.
Gidengil  CA, Mehrotra  A, Beach  S, Setodji  C, Hunter  G, Linder  JA.  What drives variation in antibiotic prescribing for acute respiratory infections?  J Gen Intern Med. 2016;31(8):918-924.PubMedGoogle ScholarCrossref
7.
Costelloe  C, Metcalfe  C, Lovering  A, Mant  D, Hay  AD.  Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis.  BMJ. 2010;340:c2096.PubMedGoogle ScholarCrossref
8.
Meeker  D, Linder  JA, Fox  CR,  et al.  Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial.  JAMA. 2016;315(6):562-570.PubMedGoogle ScholarCrossref
9.
Semigran  HL, Linder  JA, Gidengil  C, Mehrotra  A.  Evaluation of symptom checkers for self-diagnosis and triage: audit study.  BMJ. 2015;351:h3480.PubMedGoogle ScholarCrossref
10.
Ternhag  A, Hellman  J.  More on U.S. outpatient antibiotic prescribing, 2010.  N Engl J Med. 2013;369(12):1175-1176.PubMedGoogle ScholarCrossref
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